DOI: 3/1/2013. This is a case of a 50 -year-old male climber who sustained a work-related injury when he twisted his low back while removing a palm tree with hooks.
The patient was subsequently diagnosed with unspecified enthesopathy, lower limb, excluding foot; and other intervertebral disc displacement, lumbar region. As per office note dated 4/14/2016, patient complains of right hip pain radiating to right groin and low back pain. Urine toxicology was performed in the office with pending results. As per appeal letter dated 5/7/2016, the patient experienced heartburn. As per visit note dated 5/12/16, the patient complains of right hip pain radiating to right groin and low back pain. The pain is constant, and moderate in intensity associated with weakness in the right leg. He rates pain as 7-8/10 on visual analog scale and reports medications provides fair relief. In addition, he complains of increased anxiety and multiple nocturnal awakenings secondary to lack of progress. He continues to ambulate with assistive device. The patient ambulates with cane favoring his left lower extremities. Examination of the lumbar spine reveals range of motion to forward flexion of 50 degrees, extension of 15 degrees and side bending of 20 degrees bilaterally. There is tenderness
…show more content…
Motor strength is 4+/5 on right ankle dorsiflexion and right ankle plantar flexion. As per treatment plan, the patient was rescheduled and has a pending schedule for qualified medical evaluator (QME) process, a request for authorization for the medications was made for Tramadol 50 mg, Nabumetone 500 mg,
Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.
The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.
There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.
On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.
Based on the progress report dated 04/05/16 by Dr. Fieser, the patient complains of pain in the left knee, left ankle and left foot, associated with numbness and tingling in the left leg/foot, as well as weakness in the left leg. He describes the pain as sharp, cutting, throbbing, dull, aching, pressure-like, cramping, shooting and shocking with muscle pain and pins-and-needles sensation.
The patient has some weakness in his left anterior tibialis (4/5) and subtle weakness in his left quadriceps.
Review of diagnostic studies and medical-legal reports is included in the physician’s notes. Objective findings note that the patient is mildly obese and appears to be in moderate pain. He does not show signs of intoxication or withdrawal. His gait is antalgic gait and is assisted by cane. Lumbar range of motion is restricted with 50 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral bending, and 10 degrees of left lateral bending. All range of motion is limited by pain. There is tenderness noted in the bilateral paravertebral muscles. Lumbar facet loading is positive on the left side. Ankle jerk is ¼ on the right and 2/4 on the left. Patellar jerk is ¼ on the right side and 2/4 on the left side. There is tenderness noted over the trochanter and pain to the lateral hip with range of motion. Right side motor strength of ankle dorsi flexor is 4/5 and ankle plantar flexor is 4/5. Hip flexor is 5-/5. Light touch sensation is decreased over the lateral calf on the left. Patient has resting tremor of the left lower extremity. His medications are Prilosec 20mg, Celebrex 200mg, Neurontin 800mg, Flexeril 10mg, Duragesic 75mcg/hour patch, Viagra 100mg, Nuvigil 150mg, and Silenor 6mg, Evzio 0.4 mg, and Norco
The ROM was restricted, 50% of normal. The paraspinal muscle strength and tone was normal. The SLR was negative bilaterally. The exam of the left lower extremity was normal. The exam of the right lower extremity was normal except mild decreased strength in the right hip flexors. A reported MRI Lumbar Imaging on 07/01/15 showed multilevel degenerative changes; Previous L4 to sacrum fusion, evidence of herniated disc or significant central stenosis or foraminal stenosis. A reported MRI L Spine on 11/05/15 revealed herniated disc L2-3 with inferior extrusion impinging on the right L3 nerve root. Assessment: The patient has continuing symptoms of pain in the right lower extremity radiating down along the anterior thigh. This is consistent with the herniated disc at the L2-3 level on the right. He had previous surgery at the L2-3 level 3 years ago for his work-related
DOI: 11/22/14. This is a 56 year old male with an injury while disconnecting a hose with built up pressure. As per initial orthopedic comprehensive report dated 4/15/16, the patient complains of constant pain to his lower back. The pain is located across the waist and radiates down into the legs. The pain is increased upon sitting, standing, walking for any length of time, crossing his legs, bending at the waist, twisting, stooping, pushing, pulling, lifting, and/or carrying any weight. The patient also experiences stiffness in the morning hours of the day. The patient experiences increased pain when coughing and sneezing. He stats that he is awaken from sleep on nightly basis. He rates his pain as 5. Examination revealed that there is hypoesthesia
Based on the progress report dated 03/28/16, the patient complains of pain to his lumbar
Based on the latest follow-up physiatric evaluation report dated 01/11/16, the patient complains of lower back pain which improves temporarily with PT but continues to radiate to his left leg with numbness, tingling and weakness. He attends PT three days per week and participates in a daily home exercise program.
The patient is a 70-year-old gentleman who presented with left hip pain of 3 weeks duration which has been worsening over the past 5 days 10/10 nonradiating pressure-like pain is worse on exertion and improved with rest is persistent. The patient's medical history is significant for gout, hypertension, diabetes, coronary disease, hypercholesterolemia, arthritis and nephrolithiasis. The patient had a right total knee replacement, 3 caths (the last one in 2003), a right rotator cuff repair, a right thumb injury and has had 6 previous hospital admissions for the right total knee replacement. Initial blood pressure is 169/70 with pulse 64 respirations of 20. The patient is afebrile and has a weight of 112 kg. The patient's physical exam is
The pain has been worsening over the left buttock area associated with tingling and numbness down to the left leg. Medical treatment to date notes physical therapy and Nonsteroidal Antiinflammatory Drugs (NSAIDs) with limited improvement. Medical history and review of system notes that the patient is significant for hypertension. Examination of the lumbar spine revealed slight loss of lumbar lordosis. On palpation, there is moderate-to-severe guarding with reproduction of deep myofascial pain on deep palpation, mostly on the left side. Pain level is 7/10 at the time of examination. Range of motion revealed forward flexion of 50 degrees, extension of 10 degrees, right lateral flexion of 20 degrees, and left lateral flexion of 20
Mr. A is a 74-year-old male who presented to the emergency department with a chief complaint of leg pain after he fell at home. He states he got up around 1 am to use the restroom, he then felt unsteady, lost his balance and fell onto his left hip. Patient was found in that position by his wife, who then called EMS services. Patient complains of sharp, continuous pain in left hip that radiates down into his left thigh. Patient admits to occasional periods of weakness, and onset occurs when changing positions from sitting to standing, where he occasionally feels like he is going to lose his balance. He describes periods of weakness as short usually around 1-2 minutes, and characterizes his
As per medical report dated 4/18/16, patient complains of discomfort without bulging. Patient had attended 2 physical therapy visits. Patient also states that he is avoiding any lifting but still having the same discomfort; however, he did find the physical therapy helpful. Objective findings revealed tenderness noted in the left inguinal area. Proximal quadriceps and Sartorius region with pain on hip flexion versus resistance. Treatment plan include continuing with physical therapy for 6 to 8 more